Managed Care Tips and Resources

Managed Care Plans

HMOs: Health Maintenance Organizations
An HMO is a Health Maintenance Organization. As a member of an HMO, you select a primary care physician from a list of doctors specifically included in that HMO's network. Your primary care physician will be the first medical provider you call or see for a medical condition. He or she will make any needed referrals to a medical specialist. Typically, these specialists will be part of the HMO network.

If you obtain care without your primary care physician's referral or obtain care from a non-network member, you may be responsible for paying the entire bill. Usually there is an exception made for emergency care.

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With some HMOs, you pay nothing when you visit in-network doctors. With other HMOs there may be a small co-payment for the visit or service. With most HMOs you will not be responsible for paying a deductible.

If you join an HMO, you should find that you have few out-of-pocket expenses for medical care -- as long as you use doctors or hospitals that are part of the HMO.

PPOs: Preferred Provider Organizations
A PPO is a Preferred Provider Organization. As a member of a PPO, you can use the doctors and hospitals within the PPO network or go outside of the network for care. You do not need a referral to see a specialist.

If you obtain care from a medical provider outside of the PPO network, you will pay more for the service. For example, a PPO might pay 90 percent of the cost for a visit with an in-network doctor but only 70 percent of the cost for a visit to a non-network doctor.

You will typically pay a co-payment for each visit/service. These co-payments are typically higher than an HMO co-payment but not always.

As a member of a PPO, you will usually be responsible for paying an annual deductible. As well, in a PPO, you should find that you have more flexibility than with an HMO, but your total out of pocket costs are likely to be somewhat higher.

POS Plans: Point of Service Plans
A POS is a Point-of-Service Plan. This is a type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs). You can decide whether to go to a network provider and pay a flat dollar or to an out-of-network provider and pay a deductible and/or a coinsurance charge.